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r <br />AppNcshons WIII Be Processed When Submitted Property Completed. ISO Sure To Sign The App[katlon, <br />ENG*AM 'e ANO/OR <br />APRLICAIrM AND/OR <br />CONTRACTOR ANO/OR <br />BROKER ANovOR <br />LHXNM ANOOOR <br />RXQL0TRATION <br />NUMBER <br />SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br />APPLICATION IF VEHICLE INVOLVED. GIVE <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES Wake --' <br />Lid. No. <br />Fen "TASLONOMM NOUt <br />rtretac to" BATU SA104 MIe Regist. No. <br />ILEAL ESTATE MSPNII Cpm <br />POULTRY •UCM AIN Ifi]IMEL.S <br />I1IMMIAMiells SER MIS � <br />fAppl►catlon Date 7 77 ; _Business/Name To Appear On Permit <br />I!Property <br />Type Permit/Service Requested: <br />Applicant Name %/v2��/ (LRS _ Address ( C- <br />_ Business Telephone No. T.' %S --Z& Z/ Emergency Telephone No. <br />Location/Adeaa <br />I Property Ownw Addrm t X I �- " } <br />L 0"ratoes Narne /(t TO IZ � Address <br />1. FOOD idSTABLISHMENTS Total Building Sq. Footage Restaurant. Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT O VENDING VEHICLE <br />0 FOOT? CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />2. HOLISIMG <br />0 HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spans <br />2. NEATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY O WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIOFCAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURA1- BATHING PLACE " <br />S. VECTOOt CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />0 KENNEL/Runways /Animal Population No. No. of Confining Cages <br />Sewage Dispnal Method <br />Solid Waste Dtso I Method <br />Water Supply Source Mama! waste Disposal Method <br />IL ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br />7. C� PLAN CHECKING FEE ❑ DANCE PERMrr <br />S. REAL ESTATE <br />REQUEST: Water Well Irnpectlon❑ Sample 13 Title Company <br />Sewage System Inspection ❑ Address Tele. No. <br />Escrow No. <br />Seiler Seller Address <br />Telephone No, Seller Agent Name <br />Service Request For Date <br />I hereby Certify that I have prepared this application and that the work will be done in accordance with San ,foaquin County <br />ordinances. state laws, and rules and reputations of the San Joaquin focal Health District., <br />APPLICANT'S SIGNATURE X <br />Title <br />Date <br />---- FOR DEPARTMENT USE ONLY <br />Fee h Due 0 ; Lr,.O riR �NrT ❑ l6R sm , . ❑ EACH ❑ 4"I! rr 1 i P"*0sd'Briwarry at . 13 -.*Y.1 a Reoa+rad By J ft 31 <br />BASE <br />EXPLANATION <br />BILLING <br />REPAITTANC£ <br />: <br />AMOLWT OLIE <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REUITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLLIS <br />PENALTI' <br />OTHER <br />OTHER <br />21 1 <br />Roe*"" by Dais Ho. Pef"I NoDNWa/b <br />rar <br />�9: lNTAL HE TH P[RWITISFAWCla 1001 [. HAZEL i Atli P,O. sea b0i aTOC1[TQ1A G �1 Y <br />